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The Call to Action

The Call to Action on E-Cigarette Use Among Youth and Young Adults 237

Goal 1. First, Do No Harm 237

Goal 2. Provide Information About the Dangers of E-Cigarette Use Among Y outh and Young Adults 239 Goal 3. Continue to Regulate E-Cigarettes at the Federal Level to Protec t Public Health 241 Goal 4. Programs and Policies to Prevent E-Cigarette Use Among Youth and

Young Adults 243

Including E-Cigarettes in Smokefree Indoor Air Policies 243

Restricting Youth Access to E-Cigarettes

244

Licensing Retailers 245

Establishing Speci�c Packaging Requirements 245 Goal 5. Curb Advertising and Marketing that Encourages Youth and Young A dults to Use E-Cigarettes 246 Goal 6. Expand Surveillance, Research, and Evaluation Related to E-Cigar ettes 247

Conclusions 249

References 250

235
236

The Call to Action 237

E-Cigarette Use Among Youth and Young Adults

The Call to Action on E-Cigarette Use Among Youth and

Young Adults

The Surgeon General issues this Call to Action on

e-cigarettes, speciifically focusing on youth and young adults, to accelerate policies and programs that can reduce e-cigarette use among young people. This Call to Action comes amid the dramatic increase in e-cigarette use among our nation"s youth and young adults. It highlights the need to implement proven strategies that will pre vent potentially harmful effects of e-cigarette use among young people. The previous chapters explained what we know and do not know about e-cigarettes and reviewed policy options. Gaps in scientiific evidence still exist, and this Call to Action is being issued while these products and their patterns of use are changing quickly. However, policies and strategies are available that can clearly reduce the public health threat posed by e-cigarette use among young people. Use of e-cigarettes is increasing rapidly among young people, even among those who have never smoked cigarettes. This Call to Action presents six goals and related strategies that should guide efforts to reduce e-cigarette use among youth and young adults. To achieve these goals, we must work together, which means working with individuals and families; civic and community leaders; public health and health care professionals; e-cigarette manufacturers and retailers; voluntary health agencies; researchers; and other stakeholders.

Stakeholders Who Can Take Action

• Individuals, parents, and families

• Teachers, coaches, and other youth inuencers

• Civic and community leaders

• Public health and health care professionals

• Researchers • Federal government

• State, local, tribal, and territorial governments • E-cigarette manufacturers, distributors, and retailers

• Voluntary health agencies, non-governmental organizations, and other community- and faith-based organizations

Goal 1. First, Do No Harmlfl

Since 1964, reports from the U.S. Surgeon General

have led the way in identifying the harms of tobacco use and detailing the most effective ways to reduce the dan gerous effects of tobacco use. For example, reports from

1994 and 2012 outlined proven strategies to prevent and

reduce tobacco use among youth and young adults (U.S.

Department of Health and Human Services [USDHHS]

1994, 2012). Building on these and other past reports,

this Call to Action considers the harms of e-cigarette use among youth and young adults and stresses the impor tance of strategies that will protect young people from the adverse consequences of these new products.

A Report of the Surgeon General

Strategy 1A.

Implement a comprehensive strategy to address

e-cigarettes that will avoid adverse consequences and give careful consideration to the risks for youth and young adults. This can be done by including e-cigarettes in policies and programs related to conventional cigarette smoking at the national, state, local, tribal, and territorial levels. We have many effective strategies to prevent tobacco use among youth and young adults (USDHHS 2012), and many of these strategies can also be applied to e-cigarettes. A strategy to address e-cigarette use among young people should be precautionary. A precautionary approach urges action to prevent harm when there is scientiific uncer tainty. That is, when there is inadequate or early knowl edge, public health decisions should be made on the basis of precaution to prevent harm, rather than on certain risk. This approach requires proof that a product is not harmful - especially for youth - rather than proof that it is harmful. The burden of proof regarding product safety should be placed on those who wish to market and sell such tobacco products, rather than the public health com munity charged with protecting the public's health. The harms of nicotine exposure in youth and young adults are well-documented in this report and warrant this Call to Action (see Chapter 3). We must protect the health of our nation's young people by assuring that there will be no harm to youth from e-cigarettes. The stakeholders iden tiified on the previous page should work together to pre vent and reduce the use of all forms of tobacco products, including e-cigarettes, among our nation's youth and young adults. A comprehensive strategy includes:

• Implementing the U.S. Food and Drug Administration"s (FDA"s) authority to regulate tobacco products in order to provide oversight of the manufacturing, distribution, and marketing of e-cigarettes, particularly as they relate to youth and young adults;

• Funding comprehensive statewide tobacco control programs at levels recommended by the Centers for Disease Control and Prevention (CDC);

• Implementing comprehensive clean indoor air policies that protect people from exposure to secondhand tobacco smoke and the aerosol emitted from e-cigarettes;

• Raising and strongly enforcing minimum age-of-sale laws for all tobacco products, including e-cigarettes, to prevent initiation at young ages;

Use of e-cigarettes can expose young people

to nicotine. Nicotine can be highly addictive and can harm brain development. Nicotine use may also lead to the use of other tobacco or nicotine-containing products. • Setting price policies for e-cigarettes, which could include taxation policies; • Restricting advertising and marketing that encour ages youth and young adults to use e-cigarettes;

• Sponsoring high-impact media campaigns to educate the public using evidence-based information about the consequences of e-cigarette use among youth and young adults, including the harms of nicotine on the developing brain; and

• Expanding tobacco control and prevention research efforts to increase our understanding of the evolving landscape of e-cigarettes.

These components make up an evidence-based

strategy. However, the e-cigarette marketplace is diverse and continues to evolve. Thus, ongoing efforts should rapidly and effectively track and adapt to such changes, thereby protecting our nation"s young people from the consequences of e-cigarette use and exposure to second hand aerosol.

238 The Call to Action

The Call to Action 239

E-Cigarette Use Among Youth and Young Adults

Strategy 1B.

Provide consistent and evidence-based messages about the health risks of e-cigarette use and exposure to secondhand aerosol from e-cigarettes.

Research on e-cigarettes is ongoing, and the

e-cigarette marketplace continues to evolve. Even so, a sufificient body of evidence justiifies actions taken now to prevent and reduce the use of e-cigarettes and exposure to secondhand aerosol from e-cigarettes, particularly among youth and young adults. Most important, many health risks are already known, and sufificient information exists to take action to minimize potential harms. The evidence is most compelling for nicotine. As part of comprehensive reviews, previous Surgeon General's reports have provided causal ifindings on the development of addiction and other

health consequences of exposure to nicotine (USDHHS 1988, 2014). Beyond addiction, intake of nicotine by young people can harm brain development (Chapter 3).

Additionally, aerosol from e-cigarettes contains

toxins that can harm the body, and the lflavorings used in these products cannot be considered safe for inhalation, either ifirsthand or secondhand (Chapter 3). For example, some lflavorings have been known to be associated with pulmonary toxicity (Allen et al. 2016). Messaging about the potential role of e-cigarettes in reducing the burden of tobacco-related diseases should note that e-cigarette products that deliver nicotine are not considered safe, particularly for youth and young adults, even before researchers fully characterize and quantify all of their health risks, including possible permanent changes to the adolescent brain and lungs.

The use of any tobacco product, including

e-cigarettes, among young people is unsafe. Goal 2. Provide Information About the Dangers of E-Cigarette Use

Among Youth and Young Adults

Once youth and young adults start using products

that contain nicotine, including e-cigarettes, they can become addicted. Such addiction has the potential to lead to long-term use of products that contain nicotine, such as cigarettes. Most adolescents who use tobacco already use more than one nicotine-containing product and are not just using e-cigarettes alone (Chapter 2). The majority of tobacco users start before they are 18 years of age, and almost no one starts after age 25 (USDHHS 2012). Therefore, the best way to protect young people from the harms of tobacco use, including e-cigarettes, is to prevent the use of these products altogether. Prevention should start with robust public policies that make it easy for youth not to use tobacco and harder for them to use any tobacco products. Parents, teachers, health professionals, and other inlfluencers of youth should be educated about the risks of e-cigarette use. They can then help educate their own children as well as other young people about the harms of e-cigarettes and the risk of a potential lifetime of nicotine addiction.

Use of e-cigarettes and exposure to nicotine

is particularly dangerous for pregnant women. Nicotine is toxic to the fetus and impairs fetal brain and lung development. Strategy 2A.

Educate parents, teachers, coaches, and other

inlfluencers of youth about the risks of e-cigarette use among youth and young adults. Parents, guardians, teachers, coaches, health profes sionals, faith leaders, and other persons whose advice and behavior inlfluence youth play critical roles in protecting youth and young adults from the harms of e-cigarette use and exposure to the secondhand aerosol emitted from these devices. Most adults are familiar with some of the dangers of using tobacco products, especially conventional cigarettes, and of exposure to secondhand tobacco smoke. Because of these dangers, many adults have taken steps to keep children safe. However, most adults are not aware of the potential risks of using e-cigarettes and exposure to secondhand aerosol, and e-cigarette marketing often pro motes these products as safe alternatives to smoking con ventional cigarettes. But messaging about the dangers is essential. For example, the use of these products can lead to nicotine addiction, harm brain development, and lead to continued tobacco use.

A Report of the Surgeon General

Parents, teachers, coaches, and others can protect their children and other young people by educating them about e-cigarettes: • Talk openly about the harms of nicotine and tobacco use.

• Express rmly the idea that young people should not use any tobacco products, including e-cigarettes.

• Do not let any individuals use e-cigarettes or other tobacco products around children.

• Ask health care providers, adults, and parents to discuss with children the health risks of using e-cigarettes, such as nicotine addiction.

• Patronize restaurants and other places that do not allow the use of e-cigarettes indoors, and let business owners that allow e-cigarette use indoors know that it is not as safe as clean air or even legal in many places.

• Make sure children"s day care centers, schools, and universities are completely tobacco-free, including being free of e-cigarettes. A comprehensive tobacco-free campus policy prohibits any tobacco use, including e-cigarettes, on school property by anyone at any time. These policies should be expanded to include school events that are held off campus.

• Prohibit tobacco and e-cigarette company sponsorship of teams or events, promotional activities, and offers of educational materials for preventing tobacco use among youth. • Make homes and cars completely tobacco-free, including the use of e-cigarettes. This means no use by family members, friends, or guests. Opening a window does not fully protect against exposure to secondhand cigarette smoke or from the secondhand aerosol from e-cigarettes. For youth and young adults to be fully protected from indoor exposure, all indoor environments must be 100% free from tobacco smoke and e-cigarette aerosol.

• Set an example by being tobacco-free.

• Provide positive support and encouragement to anyone who is trying to quit tobacco.

E-cigarettes are now the most common form

of tobacco used by young people. High school students use e-cigarettes more than adults.

Research suggests that youth and young adults are

not as aware of the health consequences of e-cigarette use as they are with the consequences of cigarette smoking (Chapter 2) (Pearson et al. 2012; Richardson et al. 2014; Tan and Bigman 2014). FDA has the authority to require health warnings on tobacco products and tobacco adver tising. In addition, FDA and other federal entities, along with state and local organizations, can carry out educa tional campaigns to better inform the public, especially parents, and increase their understanding of the harms of e-cigarette use.

240 The Call to Action

The Call to Action 241

E-Cigarette Use Among Youth and Young Adults

Strategy 2B.

Educate health professionals about the risks of

e-cigarette use among youth and young adults. The health care setting is an ideal place to educate people of all ages on the potential risks of e-cigarette use and exposure to secondhand aerosol from e-cigarettes. Because e-cigarettes are a relatively new product, health care professionals frequently face a lot of questions about them. These often include questions related to the risks of using e-cigarettes and whether these products can help people to quit smoking. No e-cigarettes have been approved as safe and effective cessation aids. For youth, in particular, sufificient evidence shows that the use of nicotine is not safe regardless of the delivery device: combustible, non-combustible, or elec

tronic (USDHHS 2014; see also Chapter 3). Thus, health care professionals should warn youth and youth inlfluencers, such as parents, about the health risks of using any product that contains nicotine, including e-cigarettes. They should also warn youth about the dangers of using other substances, such as marijuana, in e-cigarette devices (American Academy of Pediatrics 2015).

Goal 3. Continue to Regulate E-Cigarettes at the Federal Level to

Protect Public Health

In 2009, the

Family Smoking Prevention and Tobacco

Control Act

(Tobacco Control Act) provided FDA with authority to regulate tobacco products in a manner that is "appropriate for the protection of public health" (e.g., §§ 906(d)(1), 907(a)(3)(A) & (a)(4)(A), and § 9

10(c)(2)(A) of

the Federal Food, Drug, and Cosmetic Act, as amended by the Tobacco Control Act) (

Family Smoking Prevention and

Tobacco Control Act

2009, p. 1786). The Tobacco Control Act

also requires FDA to consider in regulatory actions the health effects at the individual and population levels, including the impacts on the initiation of measures taken to quit tobacco use as well as effects on relapse among former tobacco users. But FDA is not the only federal agency that can address cer tain aspects of e-cigarettes (see Chapter 5, Table 5.2).

Strategy 3A.

Implement FDA regulatory authority over the manufac turing, marketing, and distribution of e-cigarettes.

A federal appellate court decision titled

Sottera,

Inc.v. Food & Drug Administration

(2010) determined that FDA can regulate e-cigarettes and other products made or derived from tobacco under the Tobacco Control Act, and that these products are not drugs or devices under the Food, Drug, and Cosmetic Act unless marketed as therapeutic or smoking cessation products. In May 2016, FDA ifinalized a rule deeming most products meeting the deifinition of a tobacco product, including e-cigarettes, subject to regulation under the Tobacco Control Act. The regulation went into effect on August 8, 2016 (but is under litigation) (FDA 2016). FDA's rule for e-cigarettes includes several provi sions that can help protect youth and young adults from the harms of e-cigarettes, such as the following:

• Prohibiting the sale of e-cigarettes to youth who are under 18 years of age (both in person and online);

• Requiring proof of age at the point of purchase;

A Report of the Surgeon General

• Prohibiting vending machine sales in all facilities where children are allowed to enter; • Prohibiting the distribution of free samples; • Requiring health warnings about nicotine on packaging and in advertisements;

• Requiring manufacturers to register their e-cigarette products with FDA and disclose the ingredients and levels of harmful and potentially harmful constituents in those products to that agency;

• Requiring premarket review of new or changed tobacco products and authorization by FDA before they can be introduced into the marketplace; and

• Requiring manufacturers that intend to market e-cigarettes for use to reduce harm or risk of tobacco-related disease to receive authorization from FDA based on scientic evidence that the product is less harmful or presents less risk to the public.

This authority allows FDA to undertake future regu latory actions, if determined appropriate for the protec tion of public health, including:

• Within constitutional limitations, restricting promotion, marketing, and advertising of e-cigarettes;

• Restricting Internet sales and requiring age verication on websites and upon delivery;

• Prohibiting characterizing avors;

• Promulgating product standards to reduce the toxicity, addictiveness, or appeal of tobacco products;

• Regulating packaging, including requiring minimum package sizes, mandating child-resistant packaging, and requiring health warnings; and

• Prohibiting self-service displays.

Despite gaining this broad authority, FDA does not have specic authority for certain regulatory actions. For example, FDA generally does not restrict tobacco use in public places, levy taxes on tobacco products, or restrict sales to only certain types of retailers (e.g., pharmacies); and FDA cannot completely eliminate nicotine in tobacco products, require prescriptions for tobacco products, or raise the minimum age for sale of tobacco products above18.

Other complementary comprehensive tobacco con

trol strategies at the state, local, tribal, and territorial levels include: • Implementing comprehensive clean indoor air laws; • Prohibiting sales to those under 21 years of age;

• Increasing prices of tobacco products; and

• Developing high-impact countermarketing campaigns. Effective action at the state and local levels is crit ical to fully protecting young people from the harms of e-cigarettes.

242 The Call to Action

The Call to Action 243

E-Cigarette Use Among Youth and Young Adults

Strategy 3B.

Reinforce other federal agencies as they implement programs and policies to address e-cigarettes. Of the other federal agencies that play a role in imple menting strategies to address e-cigarettes (see Chapter 5, Table 5.2), some target speciific populations (e.g., the U.S.

Department of Defense and the U.S. Department

of Veterans Affairs); others cover speciific areas (e.g., the General Services Administration, National Park Service); and some focus on certain aspects of e-cigarettes (e.g., the Federal Trade Commission, the U.S. Department of Transportation, and the U.S. Environmental Protection Agency). Speciific strategies to address e-cigarettes could include those that protect employees, customers, and visitors from exposure to secondhand aerosol, support and encourage tobacco cessation, and curb youth-targeted or false advertising. For example, the National Park Service (2015) implemented a policy to protect employees and visitors from exposure to secondhand aerosol from e-cigarettes.

Goal 4. Programs and Policies to Prevent E-Cigarette Use Among

Youth and Young Adults

Subject to certain exceptions, the Tobacco Control Act does not limit the authority of state, local, tribal, and territorial governments to enact any tobacco-related policies related to the sale, distribution, or possession of tobacco products; exposure to these products; or access to them. This broad preservation of authority enables states and localities to adopt many comprehensive tobacco control strategies that have been proven to prevent and reduce tobacco use among youth and young adults. That means that state, local, tribal, and territorial governments could act ifirst in developing regulations, policies, and pro grams that minimize any individual- and population-level harms of e-cigarettes. The strongest, most innovative tobacco control policies typically have originated at the local level before eventually being adopted at the state level. However, it is important that these strategies are developed with evaluators and epidemiologists that can collect robust data to inform the implementation and sus tainment of such strategies.

Strategy 4A.

State, local, tribal, and territorial governments should implement population-level strategies to reduce e-cigarette use among youth and young adults, such as including e-cigarettes in smokefree indoor air policies, restricting youth access to e-cigarettes in retail settings, licensing retailers, and establishing speciific package requirements.

Over 50 years of research offers a strong body of

evidence on the effectiveness of certain tobacco preven tion and control measures. Much of this evidence can also be applied to e-cigarettes. And from this evidence, state, local, tribal, and territorial entities can take a variety of actions to address e-cigarettes, such as: • Including e-cigarettes in smokefree indoor air policies; • Restricting youth access to e-cigarettes in retail settings;

• Licensing retailers; and

• Establishing specic package requirements.

Including E-Cigarettes in Smokefree

Indoor Air Policies

Most smokefree indoor air policies were put in place before the great rise in e-cigarette use. Because of that, these policies may not cover e-cigarettes or exposure to

A Report of the Surgeon General

the aerosol they produce. Aerosol from e-cigarettes is not harmless (CDC 2014). Smokefree indoor air policies should be updated to prohibit the use of both conven tional cigarettes and e-cigarettes, thereby preserving stan dards for clean indoor air. Efforts to include e-cigarettes in smokefree laws should also uphold or strengthen, not weaken, existing protections against exposure to second hand smoke. Including e-cigarettes in smokefree indoor air poli cies can: • Eliminate health risks from exposure to secondhand aerosol from e-cigarettes; • Discourage people from using both combustible and electronic tobacco products (dual use); • Simplify compliance with and enforcement of existing smokefree laws; • Help to reduce the use of e-cigarettes among youth and young adults; and

• Maintain tobacco-free norms.

Aerosol from e-cigarettes is not harmless.

To date, several states and several hundred com

munities include e-cigarettes in comprehensive smoke free laws that prohibit smoking in all indoor areas of public places, including worksites, restaurants, bars, and gambling facilities (Americans for Nonsmokers' Rights

Foundation 2015; CDC n.d.).

Restricting Youth Access to

E-Cigarettes

When laws prohibiting tobacco sales to youth are

strong and actively enforced with the education of retailers, they successfully reduce tobacco use among youth (Task Force on Community Preventive Services 2001; Zaza et al.

2005). To date, all 50 states and the District of Columbia

restrict the sale of tobacco products to minors (CDC n.d.). Extending such laws to include e-cigarettes can further protect youth from exposure to nicotine, which nearly all states have done. Speciific strategies can be implemented to deter the access of youth to e-cigarettes and their use in this population: • Restricting the sale of e-cigarettes to minors;

• Placing restrictions on Internet sales of all tobacco products and e-cigarettes, including requirements for verifying age and providing identication at the time of purchase and upon delivery;

• Requiring age verication at the point of purchase; • Displaying clear signage in retail locations about required age for sale; • Prohibiting the sale of e-cigarettes from vending machines; • Eliminating self-service displays of e-cigarettes; and • Enforcing laws on the retail sale of e-cigarettes to minors.quotesdbs_dbs8.pdfusesText_14

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